What's the highest INR you've seen? | Figure 1

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What's the highest INR you've seen?

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Enlighten me if I'm off track:
Again, you must be prepared to interpret an elevated D-dimer level before requesting the assay. More often than not, clinicians avoid the test because of the perception that they are medicolegally bound to investigate raised D-dimers, so they prefer not to know!
A negative D-dimer test is very helpful in excluding thromboembolism in low-risk patients, however ignoring a positive result without follow-up requires clinical authority. When asking to know D-dimer levels, be prepared to go all the way: initiate treatment and request CT pulmonary angiography and Doppler ultrasonography if suspecting PE and DVT, respectively.
A negative D-dimer test is useless in a high-risk PE/DVT patient, so do not request it in the first place! Treat the patient and organize imaging without hesitation.

COVID-19 Case Report

COVID-19 (coronavirus disease-2019) infection is a highly prothrombotic state, resulting from a dysregulation of the coagulation cascade. Therefore, thromboprophylaxis is strongly recommended in these patients, with some experts even advocating for therapeutic dosing to prevent thromboembolic events. Heparin-induced thrombocytopenia (HIT) is a well-known complication of heparin therapy. In this article, we report a case of HIT in a patient with COVID-19. A 63-year-old male presented with 1 week of dry cough and diarrhea. He had a positive nasopharyngeal COVID-19 reverse-transcriptase–polymerase chain reaction. On admission, the platelet count and liver function tests were within normal limits. During his hospitalization, he developed a right femoral deep venous thrombosis and was started on therapeutic anticoagulation. Due to worsening respiratory failure, he was intubated and mechanically ventilated. Between days 11 and 12 of hospitalization, platelet count dropped from 304 000 to 96 000 cells/µL. He had a high pretest probability for HIT with a 4T score of 6 and a positive anti-PF4/heparin antibody. Heparin drip was discontinued and was switched to argatroban. The serotonin release assay eventually returned positive, which confirmed the diagnosis of HIT. We also discuss potential overdiagnosis of HIT in COVID-19 through 4 cases with false-positive HIT antibodies.

Article Review: "Paget-Schroetter syndrome in athletes: a comprehensive and systematic review"
Rachel E. Keller, BS, Damari P. Croswell, BS, Giovanna I.S. Medina, MD, PhD, Timothy T.W. Cheng, MD, Luke S. Oh, MD
J Shoulder Elbow Surg (2020) 29, 2417–2425
Level IV; Systematic Review
The purpose of this review was to analyze the literature and characterize PSS in the athletic population, including risk of PSS by sport.
Setting: Department of Orthopaedic Surgery, Sports Medicine Service, Massachusetts General Hospital, Boston, MA, & Department of Orthopaedic Surgery, Harvard Medical School, Boston, MA, USA
Paget-Schroetter syndrome (PSS) is also known as "effort thrombosis." PSS is defined as axillosubclavian vein thrombosis most commonly seen in athletes or individuals with a history of significant repetitive overhead shoulder abduction and external rotation.
The authors conducted a systematic review of the literature extracting patient age, sex, hand dominance, location of thrombus, sport played, and any sport-specific details (position, level of play, changes in training), past medical history, treatment course, complications, outcomes, and return to sport (RTS). A proportional incidence ratio was calculated by determining the total number of cases of PSS and dividing the number of occurrences in each sport by that total number.
They identified 50 reports consisting of 123 Olympic sport–related cases of PSS. The average age of patients in this review was 23.99 years (range of 16-56 years). The majority were male (80.5%) and 55.3% of cases occurred in the dominant arm. The most common site for thrombus formation was the subclavian vein (53.7%). The average time from symptom onset to diagnosis was 13.4 days. The leading percent of cases reported per sport - baseball (26.8%), weight lifting (19.5%), and swimming (13%). Of the 33 cases in baseball, 70% were pitchers. RTS was only reported for 72 athletes. The average RTS for this cohort was 4.78 months. Complications associated with PSS occurred in 26.7% of the cases identified with pulmonary embolism as the most frequent complication reported, including operatively treated complications. The majority of cases in this review were treated operatively (77.2%). The authors concluded that athletes presenting with upper extremity pain and swelling with a history of playing baseball or weightlifting should be considered high risk for the development of PSS. Prompt identification is important to avoid delay in treatment to allow for a timely RTS with minimal complications.